The medial upper arm flap is a time-honored yet ignored technique. It may be revitalized by combining the techniques of tissue expansion and perforator flap surgery. Pre-expansion increases flap dimension, remodels flap vasculature, and reduces donor site morbidities, making the medial arm flap a more effective option for various defect reconstructions. A pre-expanded brachial artery perforator flap achieves excellent functional and aesthetic outcomes in patients with soft tissue defects on the head and neck, axilla, chest wall, and upper extremity. Although this technique requires multiple procedures, each operation is relatively simple and has a low complication rate when properly performed.
Key points
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Brachial artery perforator flap is a flap based on septocutaneous perforators derived from the brachial artery, which is harvested from the medial upper arm.
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The brachial artery perforator flap is commonly used as a pedicled flap for defect reconstruction in different locations, including the head and neck, axilla, chest wall, and upper extremity.
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Many of the disadvantages of the pedicled brachial artery perforator flap can be overcome by pre-expansion of the flap.
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As there is no need to dissect the perforators through the muscle, the pre-expanded pedicled brachial artery perforator flap is quite reliable and easily to be raised.
Introduction
Early in 1597, Tagliacozzi first used the inner side of the arm as a distally based flap for nasal reconstruction. The medial upper arm flap, first described by Daniel and colleagues and further investigated by Dolmans and colleagues, Kaplan and Pearl, and Song and colleagues, has been considered a valuable reconstructive option. However, the medial arm flap has not gained popularity, and the reasons may lie in the variations in vascular anatomy, which can lead to confusion during dissection. The brachial artery and its main branches have been described as the blood supply of the medial arm flap. The applications of the medial arm skin as a free flap is limited ; in most circumstances, it is used as a pedicled flap to reconstruct the defects on the head and neck and upper extremity. At present, the medial arm flap is not conceived as a workhorse flap in the reconstructive armamentarium. Nevertheless, the medial arm skin is thin and pliable, well matched to the facial skin, and well camouflaged as a donor site, and these characteristics deserve further investigation.
The perforator flap constitutes the latest development in reconstructive surgery. When raising a perforator flap, the main source vessels and relevant muscles can be spared, minimizing donor site morbidities. Early in 1990, Carriquiry demonstrated the versatility of fasciocutaneous flaps based on the medial septocutaneous vessels of the arm. By cadaveric studies and clinical observations, the authors also observed that many septocutaneous perforators from the brachial artery emerged from the medial intermuscular septum of the arm. Elevating a flap based on these perforators will not require the opening of the intermuscular septum, and the difficulty and risks of the surgery are subsequently reduced. In addition, when raising a wide and long medial arm flap, the donor site may not be closed directly and the blood supply of the distal portion of the flap may be insufficient. A well-established technique, tissue expansion increases the vascularity and dimension of the flap as well as reduces donor site morbidity. A significant increase in perforator artery diameter secondary to the pre-expansion procedure was demonstrated. In this article, the authors demonstrated the value of pre-expanded brachial artery perforator flaps for soft tissue reconstruction and summarize their experiences in using this technique for patients with soft tissue defects of the head and neck, axilla, chest wall, and upper extremity.
Introduction
Early in 1597, Tagliacozzi first used the inner side of the arm as a distally based flap for nasal reconstruction. The medial upper arm flap, first described by Daniel and colleagues and further investigated by Dolmans and colleagues, Kaplan and Pearl, and Song and colleagues, has been considered a valuable reconstructive option. However, the medial arm flap has not gained popularity, and the reasons may lie in the variations in vascular anatomy, which can lead to confusion during dissection. The brachial artery and its main branches have been described as the blood supply of the medial arm flap. The applications of the medial arm skin as a free flap is limited ; in most circumstances, it is used as a pedicled flap to reconstruct the defects on the head and neck and upper extremity. At present, the medial arm flap is not conceived as a workhorse flap in the reconstructive armamentarium. Nevertheless, the medial arm skin is thin and pliable, well matched to the facial skin, and well camouflaged as a donor site, and these characteristics deserve further investigation.
The perforator flap constitutes the latest development in reconstructive surgery. When raising a perforator flap, the main source vessels and relevant muscles can be spared, minimizing donor site morbidities. Early in 1990, Carriquiry demonstrated the versatility of fasciocutaneous flaps based on the medial septocutaneous vessels of the arm. By cadaveric studies and clinical observations, the authors also observed that many septocutaneous perforators from the brachial artery emerged from the medial intermuscular septum of the arm. Elevating a flap based on these perforators will not require the opening of the intermuscular septum, and the difficulty and risks of the surgery are subsequently reduced. In addition, when raising a wide and long medial arm flap, the donor site may not be closed directly and the blood supply of the distal portion of the flap may be insufficient. A well-established technique, tissue expansion increases the vascularity and dimension of the flap as well as reduces donor site morbidity. A significant increase in perforator artery diameter secondary to the pre-expansion procedure was demonstrated. In this article, the authors demonstrated the value of pre-expanded brachial artery perforator flaps for soft tissue reconstruction and summarize their experiences in using this technique for patients with soft tissue defects of the head and neck, axilla, chest wall, and upper extremity.
Treatment goals and planned outcomes
The authors applied the pre-expanded brachial artery perforator flap mainly in patients with scar, congenital melanocytic nevi, hemangioma, and neurofibroma of the head and neck, axilla, chest wall, and upper extremity to achieve excellent functional and aesthetic outcomes. This technique can provide a large, thin flap with similar color, texture, and thickness for head and neck defect reconstruction. The authors’ experience with more than 50 flaps supports the claim that this technique is safe and successful in achieving superior aesthetic results. When properly planned and performed, these operations have a low complication rate and minimal donor site morbidity.
Anatomic basis of the brachial artery perforator flap
The brachial artery is the continuation of the axillary artery beyond the teres major and primarily supplies the arm. The artery courses through the intermuscular septum between the biceps and the triceps. The principal tributaries of the brachial artery include the profunda brachial artery, the superior and inferior ulnar collateral arteries, and many muscular and cutaneous branches ( Fig. 1 ).
The authors focused on investigating the septocutaneous perforators from the brachial artery nourishing the medial skin of the arm by means of cadaveric dissection and clinical observation. They found that 1 to 3 septocutaneous perforators originating from the brachial artery along the medial septum can be identified in 1 of 3 portions of the medial arm. Meanwhile, at least one arterial perforator with visible pulsation and 2 venae comitantes can be found in the proximal, middle, and distal portions of the medial arm, respectively. The proximal and distal perforators densely distribute in the regions 3 cm distal to the central axillary fold and 5 cm proximal to the medial epicondyle, respectively ( Figs. 2 and 3 ). They also found that close to the central axillary fold, the brachial artery consistently gives rise to an uppermost branch. The latter, 1 to 3 mm in diameter, not only sends muscular branches to adjacent muscles and septocutaneous perforators to the medial arm skin, but, most notably, also sends a long superficial thoracic branch. The long superficial thoracic branch, accompanied by 2 venae comitantes, 2 to 3 cm lateral and parallel to the lateral margin of the pectoralis muscle, travels within the subcutaneous fatty tissue of the lateral chest wall and terminates in the superficial fascia around the nipple-areola complex ( Fig. 4 ).
Preoperative planning and preparation
Before the implantation of the tissue expander, the dimension of the wound is evaluated. The authors routinely explore the location of the perforators preoperatively ( Fig. 5 ). According to the location and size of the defect, one side of the medial arm is chosen as the donor area. The central axis of the flap is drawn along the medial intermuscular septum of the arm, roughly corresponding to the surface projection of the brachial artery. Two vertical lines traversing the central axillary fold and medial epicondyle of humerus are also drawn, respectively, corresponding to the superior and inferior margins of the medial arm. The lateral margins are between the midanterior and midposterior lines of the arm. The pre-expanded area can be extended to the superior or inferior margins of the medial arm, in accordance with the location of the flap pedicle ( Fig. 6 ).
